The Patient Aligned Care Team (PACT) Nurse Care Manager (NCM) is a member of the PACT Team let (Primary Care Provider, Nurse Care Manager, Licensed Practical Nurse, Health Technician, and Clerical Associate) and supports the work of the expanded team (Pharmacist, Social Worker, Home Telehealth RN, Psychologist, and Dietician).
Major duties and responsibilities include, but are not limited to: - Demonstrates advanced clinical knowledge in assessing, planning, implementing, documenting, and evaluating care for an assigned panel of patients at Fayetteville Coastal Health Care System - Recognizing the age-related cognitive, physical, emotional, and chronological maturation needs of the adult and geriatric patient focusing on chronic disease management.
- Identifies and provides case management for high-risk cohort of patients utilizing chronic disease management data mining tools to include but not limited to Care Management Tool (CMT), Business Intelligent Strategic Learning (BISL), VISN 6 Access Report, VISTA, and VHA Support Service Center (VSSC) reports such as PC Almanac, Compass, Primary Care Management Module (PCMM) Care Needs Assessment (CNA).
- Utilizes other registries to manage disease processes such as Diabetic, Mammography, Cardiovascular, and Opioid Registries to access data base for pain management. - Performs timely Post-Discharge/ ED/ Urgent Care, walk-ins, and schedule visits are addressed using appropriate documentation templates/notes, codes, education. - Ensures Secure Messaging and telephone contacts are addressed timely.
- Assesses and enrolls eligible patients into nontraditional modalities of care such as Home telehealth and Telemedicine. Utilizes Teach and Motivational Interviewing techniques to encourage positive health behavioral change and Health Promotion and Disease Prevention. Provides patient and family education with a focus on self-management, prevention, and wellness, based on 'what matters most' to the patient.
Reviews, tracks, and devises strategies to improve Healthcare Effective Data Information Sets (HEDIS) metrics, clinical reminders, panel access, timely encounter closures, and other performance metrics. - Facilitates continuity of care by partnering with multidisciplinary services, internal and external to the Department of Veterans Affairs. - Initiates and participates in various quality and process improvement activities that result in improved patient outcomes.
- Enhances clinic access and team performance by pre-planning/ pre-appointment chart review huddles and weekly meetings with PACT teamlet and other members of the extended PACT. Utilizes facility approved Nursing Protocols and Guidelines to enhance patient care as appropriate. Collaborates with PACT and extended PACT to participate/provide shared medical appointments/group clinics for patients with specific chronic disease diagnosis.
- Demonstrates leadership by serving as an advocate for patients and a team leader with colleagues as he/she continues to enhance his/her own professional growth, continuing education and development. - Completes any other nursing responsibilities as assigned by leadership.
VA offers a comprehensive total rewards package: VA Nurse Total Rewards Pay: Competitive salary, regular salary increases, potential for performance awards Paid Time Off: 50 days of paid time off per year (26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year) Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Licensure: 1 full and unrestricted license from any US State or territory Work Schedule: Monday - Friday 0800 - 1630 Telework: Ad-hoc Virtual: This is not a virtual position.
Relocation/Recruitment Incentives: Not authorized Permanent Change of Station (PCS): Not authorized
Allan.thongrattana@va.gov · 951-517-6941
This position is with Veterans Health Administration, Department of Veterans Affairs.
The posted pay range is $87200 – $145373/yr.
Applications close on 2026-10-16.
This position is open under the 'Fed Internal Search' hiring path.
Source: USAJOBS.gov — U.S. Federal Government
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